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McGee SF, Mazzarello S, Caudrelier JM, Lima MAG, Hutton B, Sienkiewicz M, Stober C, Fernandes R, Ibrahim MFK, Vandermeer L, Hilton J, Shorr R, Fergusson D, Clemons M. Optimal sequence of adjuvant endocrine and radiation therapy in early-stage breast cancer - A systematic review. Cancer Treat Rev 2018; 69:132-142. [PMID: 30014951 DOI: 10.1016/j.ctrv.2018.06.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 06/18/2018] [Accepted: 06/19/2018] [Indexed: 01/02/2023]
Abstract
IMPORTANCE Clinical equipoise exists around the optimal time to start adjuvant endocrine therapy in patients who will receive post-operative radiotherapy for breast cancer. Concerns continue to exist regarding potential reduced efficacy, or increased toxicity, when radiation, and endocrine therapy are administered concurrently. OBJECTIVE To perform a systematic review of studies comparing outcomes between sequential and concurrent adjuvant radiation and endocrine therapy in early-stage breast cancer. All modalities of radiation therapy were considered, and endocrine therapy could be either tamoxifen or an aromatase inhibitor. Outcomes of interest included; local, regional or distant recurrence, overall survival and treatment-related toxicities. EVIDENCE REVIEWED PubMed, Ovid Medline, EMBASE, and the Cochrane Central Register of Controlled Trials were searched from 1946 to December 2017. Two reviewers independently assessed each citation using the criteria outlined above. Study quality was assessed using the Cochrane Collaboration's tool for prospective studies, and the Newcastle-Ottawa scale for retrospective studies. FINDINGS Of 2137 unique citations identified, 13 met eligibility criteria. Eleven were unique studies (7569 patients), while 2 of the studies were updated analyses of previous studies. Studies evaluated the timing of adjuvant radiation, and tamoxifen (5 studies, 1550 patients), or aromatase inhibitors (6 studies, 6019 patients). We identified 1 complete randomized clinical trial (150 patients), and 5 retrospective studies (1580 patients), in addition to conference abstracts (5 studies, 5839 patients). Overall, none of the studies showed a significant difference in efficacy, or toxicity, with concurrent versus sequential treatment. However, given the significant heterogeneity of the study populations, it was not possible to conduct a meta-analysis. CONCLUSIONS AND RELEVANCE In the absence of high quality data, adequately powered randomized trials are required to answer this important clinical question.
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Affiliation(s)
- S F McGee
- Department of Medicine and Division of Medical Oncology, University of Ottawa, Ottawa, ON, Canada
| | - S Mazzarello
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - J M Caudrelier
- Department of Radiation Medicine, The Ottawa Hospital Cancer Centre, Ottawa, ON, Canada
| | - M A G Lima
- Instituto do Câncer do Estado de São Paulo, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - B Hutton
- Clinical Epidemiology Department, The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - M Sienkiewicz
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - C Stober
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - R Fernandes
- Division of Medical Oncology, Department of Oncology, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - M F K Ibrahim
- Department of Medicine and Division of Medical Oncology, University of Ottawa, Ottawa, ON, Canada
| | - L Vandermeer
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - J Hilton
- Department of Medicine and Division of Medical Oncology, University of Ottawa, Ottawa, ON, Canada; The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - R Shorr
- The Ottawa Hospital, Ottawa, ON, Canada
| | - D Fergusson
- Clinical Epidemiology Department, The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - M Clemons
- Department of Medicine and Division of Medical Oncology, University of Ottawa, Ottawa, ON, Canada; The Ottawa Hospital Research Institute, Ottawa, ON, Canada.
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Quan K, Xu KM, Lalonde R, Horne ZD, Bernard ME, McCoy C, Clump DA, Burton SA, Heron DE. Treatment Plan Technique and Quality for Single-Isocenter Stereotactic Ablative Radiotherapy of Multiple Lung Lesions with Volumetric-Modulated Arc Therapy or Intensity-Modulated Radiosurgery. Front Oncol 2015; 5:213. [PMID: 26500888 PMCID: PMC4594030 DOI: 10.3389/fonc.2015.00213] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Accepted: 09/18/2015] [Indexed: 01/24/2023] Open
Abstract
The aim of this study is to provide a practical approach to the planning technique and evaluation of plan quality for the multi-lesion, single-isocenter stereotactic ablative radiotherapy (SABR) of the lung. Eleven patients with two or more lung lesions underwent single-isocenter volumetric-modulated arc therapy (VMAT) radiosurgery or IMRS. All plans were normalized to the target maximum dose. For each plan, all targets were treated to the same dose. Plan conformity and dose gradient were maximized with dose-control tuning structures surrounding targets. For comparison, multi-isocenter plans were retrospectively created for four patients. Conformity index (CI), homogeneity index (HI), gradient index (GI), and gradient distance (GD) were calculated for each plan. V5, V10, and V20 of the lung and organs at risk (OARs) were collected. Treatment time and total monitor units (MUs) were also recorded. One patient had four lesions and the remainder had two lesions. Six patients received VMAT and five patients received intensity-modulated radiosurgery (IMRS). For those treated with VMAT, two patients received 3-arc VMAT and four received 2-arc VMAT. For those treated with IMRS, two patients were treated with 10 and 11 beams, respectively, and the rest received 12 beams. Prescription doses ranged from 30 to 54 Gy in three to five fractions. The median prescribed isodose line was 84% (range: 80–86%). The median maximum dose was 57.1 Gy (range: 35.7–65.1 Gy). The mean combined PTV was 49.57 cm3 (range: 14.90–87.38 cm3). For single-isocenter plans, the median CI was 1.15 (range: 0.97–1.53). The median HI was 1.19 (range: 1.16–1.28). The median GI was 4.60 (range: 4.16–7.37). The median maximum radiation dose (Dmax) to total lung was 55.6 Gy (range: 35.7–62.0 Gy). The median mean radiation dose to the lung (Dmean) was 4.2 Gy (range: 1.1–9.3 Gy). The median lung V5 was 18.7% (range: 3.8–41.3%). There was no significant difference in CI, HI, GI, GD, V5, V10, and V20 (lung, heart, trachea, esophagus, and spinal cord) between single-isocenter and multi-isocenter plans. This multi-lesion, single-isocenter lung SABR planning technique demonstrated excellent plan quality and clinical efficiency and is recommended for radiosurgical treatment of two or more lung targets for well-suited patients.
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Affiliation(s)
- Kimmen Quan
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute , Pittsburgh, PA , USA
| | - Karen M Xu
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute , Pittsburgh, PA , USA
| | - Ron Lalonde
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute , Pittsburgh, PA , USA
| | - Zachary D Horne
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute , Pittsburgh, PA , USA
| | - Mark E Bernard
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute , Pittsburgh, PA , USA
| | - Chuck McCoy
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute , Pittsburgh, PA , USA
| | - David A Clump
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute , Pittsburgh, PA , USA
| | - Steven A Burton
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute , Pittsburgh, PA , USA
| | - Dwight E Heron
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute , Pittsburgh, PA , USA
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